Unintended second pregnancies could be avoided

A community health worker holds up contraceptives during a lecture on family planning at a reproductive health clinic run by an Non-Governmental Organization (NGO) in Manila January 12, 2016. REUTERS/Janis Alano
(Copyright Reuters 2016)

Most unintended pregnancies within two years of a woman giving birth could have been prevented or postponed if women had access to the long-acting contraception of their choice, according to a study in Texas.

"A lot needs to be done to make access to highly effective contraception a reality for low income or uninsured women," said lead author Joseph E. Potter of the Population Research Center at the University of Texas at Austin. "Counseling is important during prenatal care so women know they have this option, and actually implementing availability of immediate postpartum long-acting reversible contraception is a very important step."

The researchers interviewed 403 women who gave birth in Austin hospitals in 2012, all of whom said they wanted to delay childbearing for at least two years. They were interviewed again three, six, nine, 12, 18 and 24 months later.

The women reported their pregnancy status and contraceptive method, and soon after giving birth they also noted their preferred contraceptive method, regardless of whether that was what they were using.

At six months postpartum, 377 women were interviewed and two-thirds said they had already encountered a barrier to using their preferred method. The problem was often a financial or health system barrier, and these women were more often using less effective methods, like condoms, or hormonal contraception.

Among women who did not have barriers, three quarters were using permanent methods like vasectomy or sterilization or long-acting reversible contraception (LARC) methods like an intrauterine device (IUD) or hormonal implant.

There were 77 reported pregnancies between six months and 24 months postpartum, including 12 percent of the women who met no barriers to contraception and about 43 percent of women who encountered financial or health system barriers, according to the results in Obstetrics and Gynecology.

Of the 71 pregnancies that were unplanned, 46 percent of women would have preferred to use a permanent birth control method, and 87 percent said they wanted to use a long-acting option or would be interested in one if it were available for free or at minimal cost.

In 2012, there was a 30-day waiting period for sterilization for Medicaid patients, which was one barrier women faced, Potter told Reuters Health.

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Texas drastically reduced public funding for subsidized family planning services in 2011, so women in 2012 may have had a harder time accessing birth control options that year than before or since, he added.

"We started recruiting in April of 2012, so that was right at the very worst time in Texas," Potter said.

There had been 79 clinic closures, and those that were open were extremely short on funds and were not able to buy long-acting contraception, he said.

Since then, funding has been reinstated and Medicaid has begun reimbursing for immediate postpartum LARC, he said.

Still, only one hospital in Texas is actually performing immediate postpartum IUD insertion or other long-acting contraception, Potter said. In other areas, women have to go to a clinic for a postpartum checkup and address contraception needs then.

"I am not surprised that the main barriers to contraceptive use are financial and health system barriers, but it is thought-provoking to see that the percentage of women who had an unintended pregnancy and would have liked to use a highly effective contraceptive method was so high," said Heike Thiel de Bocanegra of the Bixby Center for Global Reproductive Health at the University of California, San Francisco, who was not part of the new study. "Short interpregnancy intervals are associated with medical problems for mother and child."

Barriers to postpartum long-acting contraception and sterilization are common in the United States, said Lauren Zapata of the National Center for Chronic Disease Prevention and Health Promotion, who also was not part of the new study.

"Measures that may increase women's access to preferred contraceptives might include: improving insurance coverage for postpartum contraceptives, authorizing reimbursement for postpartum LARC and eliminating the 30-day waiting period for sterilization of Medicaid patients, and ensuring women have access to the full range of methods while they are still having regular or scheduled appointment with obstetric providers," Zapata told Reuters Health by email.